Intravitreal triple therapy with vancomycin, ceftazidime, and moxifloxacin for bacterial endophthalmitis: A Twelve-year experience.

PURPOSE: Increasing rates of antibiotic resistance in endophthalmitis have been reported. This study examines outcomes of triple therapy with intravitreal vancomycin, ceftazidime, and moxifloxacin for endophthalmitis. METHODS: Retrospective, consecutive series of all patients treated with abovementioned intravitreal antibiotics from January 2009 to June 2021. Percentages of eyes attaining greater than or equal to 20/200 and 20/50 Snellen visual acuities and adverse events were evaluated. RESULTS: 112 eyes met inclusion criteria. 63 of 112 eyes (56%) achieved a visual acuity of 20/200 during follow-up, with 39 (35%) returning to at least 20/50. In subgroup analysis, 23 of 24 (96%) eyes with post-cataract endophthalmitis obtained ≥ 20/200 acuity and 21 of 24 (88%) obtained ≥ 20/50 acuity during follow-up. There were no cases of macular infarction. CONCLUSIONS: Intravitreal moxifloxacin (160 µg/0.1 mL) was well tolerated as an adjunct to vancomycin and ceftazidime for bacterial endophthalmitis. Use of this novel combination offers several theoretical advantages compared to standard therapy with two antibiotics, including expanded gram-negative coverage and potential synergy, and may be particularly valuable in geographies where the local antibiogram supports empiric use. Further study is merited to verify the safety and efficacy profile.

Time-driven Activity-based Costing Analysis of Fluorescein Angiography.

PURPOSE: To use electronic health record (EHR) time logs and time-driven activity-based costing (TDABC) to calculate the complete cost profile of office-based fluorescein angiography (FA). DESIGN: Economic analysis. SUBJECTS: Patients undergoing routine FA (Current Procedural Terminology [CPT] 92235) at Vanderbilt Eye Institute in fiscal year 2022. METHODS: Process flow mapping for routine FA was used to define the care episode after manual observation. Deidentified time logs were sourced from the EHR and all manually validated to calculate durations for each stage. The cost of materials was calculated from internal financial figures. Cost per minute for space, equipment, and personnel were based on internal figures. Published fluorescein costs were used for base-case analysis with scenario analysis based on a range of internal figures from pharmacy quotes. These inputs were used for a TDABC analysis. MAIN OUTCOME MEASURES: Time-driven activity-based costing of FA episode of care. Secondary scenario analyses focus on breakeven scenarios for key inputs, including medication costs RESULTS: Cost analysis of office-based FA resulted in an average total cost of $152.95 (nominal) per interpreted study per patient, which was $36.52 more than the maximum Medicare reimbursement for CPT 92235 in Mac Locality for Tennessee 10312 for fiscal year 2022 ($116.43; $76.11 [technical component] and $40.33 [physician component]). The negative contribution margin is strongly influenced by the cost of fluorescein, which comprises 39.8% of the episode costs, excluding overhead. CONCLUSIONS: The current analysis here shows that the recently increased cost of fluorescein has driven up the cost of office-based FA relative to the current maximum allowable Medicare reimbursement, leading to a negative contribution margin and financial loss. Given conservative cost estimates here, it is unlikely for profitability to be achieved without changes in the cost of fluorescein or increased reimbursement. These results may be informative for policy discussion regarding appropriate reimbursement for codes using injectable fluorescein. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Automated instrument-tracking for 4D video-rate imaging of ophthalmic surgical maneuvers.

Intraoperative image-guidance provides enhanced feedback that facilitates surgical decision-making in a wide variety of medical fields and is especially useful when haptic feedback is limited. In these cases, automated instrument-tracking and localization are essential to guide surgical maneuvers and prevent damage to underlying tissue. However, instrument-tracking is challenging and often confounded by variations in the surgical environment, resulting in a trade-off between accuracy and speed. Ophthalmic microsurgery presents additional challenges due to the nonrigid relationship between instrument motion and instrument deformation inside the eye, image field distortion, image artifacts, and bulk motion due to patient movement and physiological tremor. We present an automated instrument-tracking method by leveraging multimodal imaging and deep-learning to dynamically detect surgical instrument positions and re-center imaging fields for 4D video-rate visualization of ophthalmic surgical maneuvers. We are able to achieve resolution-limited tracking accuracy at varying instrument orientations as well as at extreme instrument speeds and image defocus beyond typical use cases. As proof-of-concept, we perform automated instrument-tracking and 4D imaging of a mock surgical task. Here, we apply our methods for specific applications in ophthalmic microsurgery, but the proposed technologies are broadly applicable for intraoperative image-guidance with high speed and accuracy.

Effect of prophylactic laser during small-gauge vitrectomy for epiretinal membranes.

PURPOSE: To determine the rate of post-operative retinal detachment after elective pars plana vitrectomy for epiretinal membrane, and to test for the mitigating effect of prophylactic endolaser. METHODS: We identified 459 eyes of 411 patients undergoing vitrectomy for epiretinal membrane at Vanderbilt University Medical Center between January 2010 and May 2017. Patients who underwent concurrent endolaser without any identified retinal break were included in the exposure cohort. Patients who underwent no prophylactic retinopexy or ablation were included in the unexposed cohort. Exposure data, demographic data, and outcome data were tabulated for comparison. RESULTS: The final analysis included 343 eyes of 343 patients. Approximately 7% of eyes undergoing ERM surgery were found to have a full-thickness retinal break which was not seen preoperatively. The overall rate of postoperative RD was 2.04%. Postoperative retinal detachment occurred in 0 of the 34 eyes exposed to prophylactic laser, and in 7 of the 309 control eyes. Odds ratio was found to be 0.60 (p = 0.598 (95%CI 0.0327-10.7), p = 0.72), indicated the results were not statistically significant. DISCUSSION: Looking at patients undergoing routine vitrectomy surgery for epiretinal membrane, no retinal detachments occurred in the group receiving prophylactic treatment, though this association did not reach statistical significance. With modern surgical techniques, post-operative retinal detachment remains relatively rare after vitrectomy for ERM though a thorough intraoperative exam is critical to identify occult retinal breaks.

Health Care Price Transparency in Ophthalmology.

IMPORTANCE: Health care price transparency legislation is intended to reduce the ambiguity of hospital charges and the resultant financial stress faced by patients. OBJECTIVE: To evaluate the availability, usability, and variability of standard reported prices for ophthalmologic procedures at academic hospitals. DESIGN, SETTING, AND PARTICIPANTS: In this multicenter economic evaluation study, publicly available price transparency web pages from Association of American Medical Colleges affiliate hospitals were parsed for standard charges and usability metrics. Price transparency data were collected from hospital web pages that met the inclusion criteria. Geographic practice cost indices for work, practice expense, and malpractice were sourced from the Centers for Medicare & Medicaid Services. Data were sourced from February 1 to April 30, 2021. Multiple regression was used to study the geographic influence on standard charges and assess the correlation between standard charges. MAIN OUTCOMES AND MEASURES: Availability and variability of standard prices for Current Procedural Terminology (CPT) codes 66984 (removal of cataract with insertion of lens) and 66821 (removal of recurring cataract in lens capsule using laser). RESULTS: Of 247 hospitals included, 191 (77.3%) provided consumer-friendly shoppable services, most commonly in the form of a price estimator or online tool. For CPT code 66984, 102 hospital (53.4%) provided discount cash pay estimates with a mean (SD) price of $7818.86 ($5407.91). For CPT code 66821, 71 hospital (37.2%) provided discount cash pay estimates with a mean (SD) price of $2041.72 ($2106.44). The top quartile of hospitals, prices wise, listed included prices higher than $10 400 for CPT code 66984 and $2324 for CPT code 66821. Usability issues were noted for 36 hospitals (18.8%), including requirements for personal information or web page navigability barriers. Multiple regression analysis found minimal explanatory value for geographic practice cost indices for cash discount prices for CPT codes 66984 (adjusted R2 = 0.54; 95% CI, 0.41-0.67; P < .001) and 66821 (adjusted R2 = 0.64; 95% CI, 0.51-0.77; P < .001). CONCLUSIONS AND RELEVANCE: Despite recent legislature that codified price transparency requirements, some current standard charges remain ambiguous, with substantial interhospital variability not explained by geographic variability in costs. Given the potential for ambiguous pricing to burden vulnerable, uninsured patients, additional legislation might consider allowing hospitals to defer price estimates or rigorously define standards for actionable cash discount percentages with provisions for displaying relevant benchmark prices.

Effect of Intravenous Chemotherapy Regimen on Globe Salvage Success Rates for Retinoblastoma Based on Disease Class-A Meta-Analysis.

To evaluate the relative efficacy of novel retinoblastoma treatments, eye classification-specific success rates for current standard-of-care intravenous chemotherapy regimens must be known. This meta-analysis included studies if: (1) patients received intravenous chemotherapy for retinoblastoma, (2) globe salvage data was reported, (3) only intravenous chemoreduction (with/without local consolidation) was used. The outcome measure was globe salvage success without need for salvage radiotherapy, subdivided by disease classification and chemotherapy regimen. Data from 27 studies (1483 eyes) were pooled. By Reese-Ellsworth classification, globe salvage rates were 85% (95%CI:73-92%) for Group I, 78% (95%CI:70-85%) for Group II, 68% (95%CI:56-78%) for Group III, 47% (95%CI:34-60%) for Group IV, and 35% (95%CI:26-45%) for Group V (Va: 35% [95%CI:21-54%]; Vb: 42% [95%CI:29-56%]; those without sub-classification: 31% [95%CI:19-47%]). By International Classification, globe salvage rates were 93% (95%CI:80-97%) for Group A, 83% (95%CI:73-89%) for Group B, 73% (95%CI:54-86%) for Group C, 40% (95%CI:31-51%) for Group D, and 19% (95%CI:5-50%) for Group E. Standard carboplatin-etoposide-vincristine out-performed two-drug regimens (odds ratio (OR) = 1.9 (95%CI:1.3-3.0) for Groups I-IV and OR = 2.1 (95%CI:1.3-3.4) for Group V; p = 0.002 for each). For eyes with diffuse vitreous seeds (Vb), an enhanced regimen out-performed standard chemotherapy (OR = 2.4 [95%CI:1.3-4.7]; p = 0.004). In conclusion, two-drug regimens were less effective for all eyes, whereas enhanced regimens were more effective for eyes with vitreous seeds. Novel therapies can now be compared to these baseline globe salvage rates.

Frequency of Urgent or Emergent Vitreoretinal Surgical Procedures in the United States During the COVID-19 Pandemic.

Importance: The American Academy of Ophthalmology (AAO) indicated that urgent or emergent vitreoretinal surgical procedures should continue during the coronavirus disease 2019 (COVID-19) pandemic. Although decreases in the frequency of critical procedures have been reported outside the field of ophthalmology, analyses are limited by volume, geography, and time. Objective: To evaluate whether the frequency of ophthalmic surgical procedures deemed urgent or emergent by the AAO changed across the United States during the COVID-19 pandemic. Design, Setting, and Participants: Vitreoretinal practices from 17 institutions throughout the US participated in this multicenter cross-sectional study. The frequency of 11 billed vitreoretinal Current Procedural Terminology (CPT) codes across respective weeks was obtained from each practice between January 1, 2019, and May 31, 2020. Data were clustered into intravitreal injections (code 67028), lasers and cryotherapy (codes 67141, 67145, and 67228), retinal detachment (RD) repairs (codes 67107, 67108, 67110, and 67113), and other vitrectomies (codes 67036, 67039, and 67040). Institutions were categorized by region (Northeast, Midwest, South, and West Coast), practice setting (academic [tax-exempt] or private [non-tax-exempt]), and date of respective statewide stay-at-home orders. Main Outcomes and Measures: Nationwide changes in the frequency of billing for urgent or emergent vitreoretinal surgical procedures during the COVID-19 pandemic. Results: A total of 526 536 CPT codes were ascertained: 483 313 injections, 19 257 lasers or cryotherapy, 14 949 RD repairs, and 9017 other vitrectomies. Relative to 2019, a weekly institutional decrease in injections was observed from March 30 to May 2, 2020, with a maximal 38.6% decrease (from a mean [SD] of 437.8 [436.3] to 273.8 [269.0] injections) from April 6 to 12, 2020 (95% CI, -259 to -69 injections; P = .002). A weekly decrease was also identified that spanned a longer interval, at least until study conclusion (March 16 to May 31, 2020), for lasers and cryotherapy, with a maximal 79.6% decrease (from a mean [SD] of 6.6 [7.7] to 1.5 [2.0] procedures) from April 6 to 12, 2020 (95% CI, -6.8 to -3.3 procedures; P < .001), for RD repairs, with a maximal 59.4% decrease (from a mean [SD] of 3.5 [4.0] to 1.6 [2.2] repairs) from April 13 to 19, 2020 (95% CI, -2.7 to -1.4 repairs; P < .001), and for other vitrectomies, with a maximal 84.3% decrease (from a mean [SD] of 3.0 [3.1] to 0.4 [0.8] other vitrectomies) from April 6 to 12, 2020 (95% CI, -3.3 to -1.8 other vitrectomies; P < .001). No differences were identified by region, setting, or state-level stay-at-home order adjustment. Conclusions and Relevance: Although the AAO endorsed the continued performance of urgent or emergent vitreoretinal surgical procedures, the frequency of such procedures throughout the country experienced a substantial decrease that may persist after the COVID-19 pandemic's initial exponential growth phase. This decrease appears independent of region, setting, and state-level stay-at-home orders. It is unknown to what extent vitreoretinal intervention would have decreased without AAO recommendations, and how the decrease is associated with outcomes. Although safety is paramount during the COVID-19 pandemic, practices should consider prioritizing availability for managing high-acuity conditions until underlying reasons for the reduction are fully appreciated.

Validation of a Standardized Home Visual Acuity Test for Teleophthalmology.

Purpose: The recent exponential growth in teleophthalmology has been limited in part by the lack of a validated method to measure visual acuity (VA) remotely. We investigated the validity of a self-administered Early Treatment Diabetic Retinopathy Study (ETDRS) home VA test. We hypothesized that a home VA test with a printout ETDRS chart is equivalent to a standard technician-administered VA test in clinic. Design: Prospective cohort study. Participants: Two hundred nine eyes from 108 patients who had a scheduled in-person outpatient ophthalmology clinic visit at an academic medical center. Methods: Enrolled patients were sent a .pdf document consisting of instructions and a printout ETDRS vision chart calibrated for 5 feet. Patients completed the VA test at home before the in-person appointment, where their VA was measured by an ophthalmic technician using a standard ETDRS chart. Survey questions about the ease of testing and barriers to completion were administered. For the bioequivalence test with a 5% nominal level, the 2 1-sided tests procedure was used, and an equivalent 90% confidence interval (CI) was constructed and compared with the prespecified 7-letter equivalence margin. Main Outcome Measures: The primary outcome was the mean adjusted letter score difference between the home and clinic tests. Secondary outcomes included the unadjusted letter difference, absolute letter difference, and survey question responses. Results: The mean adjusted VA letter score difference was 4.1 letters (90% CI, 3.2-4.9 letters), well within the 7-letter equivalence margin. Average unadjusted VA scores in clinic were 3.9 letters (90% CI, 3.1-4.7 letters) more than scores at home. The absolute difference was 5.2 letters (90% CI, 4.6-5.9 letters). Ninety-eight percent of patients agreed that the home test was easy to perform. Conclusions: An ETDRS VA test self-administered at home following a standardized protocol was equivalent to a standard technician-administered VA test in clinic in the examined population.

REVERSE SUTURE TECHNIQUE FOR INTRAOCULAR LENS REFIXATION.

PURPOSE: To describe a novel reverse suture approach to safely and securely refixate dislocated intraocular lenses (IOLs). METHODS: We describe two cases herein where we use a reverse suture technique to refixate dislocated IOLs. By reversing the needle-holder grasp on a Gore-Tex suture needle, we can safely insert the base of the needle through the pars plana. This allows for looping of the suture around the haptic of subluxated or dislocated IOL. We use the technique in a case with a subluxed plate haptic IOL and a subluxed three-piece IOL with an encircling capsular tension ring. RESULTS: The reverse suture technique allows for safe and effective looping of a subluxed IOL haptic or capsular tension ring. This technique can be performed without an assistant and prevents excessive manipulation and unnecessary explantation of dislocated IOL. CONCLUSION: The reverse suture technique is a safe, effective, and easily reproducible maneuver to refixate dislocated IOLs.

Prophylaxis measures for postinjection endophthalmitis.

Intravitreal injections have become the most commonly performed ophthalmic procedure, transforming modern retina practice. Postinjection endophthalmitis, while rare, remains the most feared potential complication. Prophylaxis measures including topical antisepsis, hand hygiene, gloves, masks, and drapes have all been proposed to help prevent postinjection endophthalmitis; however, there remains significant variation in protocol, given the lack of agreement among retina specialists on which steps are crucial to prevent endophthalmitis. With millions of injections performed annually, collating data have helped us better understand risk factors for endophthalmitis after intravitreal injection. We summarize the consensus guidelines for intravitreal injection technique and comprehensively review the literature on prevention of postinjection endophthalmitis.

Air vs Gas Tamponade During Macular Hole Repair Surgery.

Purpose: This work investigates the visual and anatomical outcomes of full-thickness macular hole (FTMH) repair surgery using air in comparison to gas tamponade. Methods: A retrospective consecutive review of medical records was undertaken of all patients undergoing pars plana vitrectomy for idiopathic FTMH at an academic practice from January 2010 to May 2017. Each operative report was reviewed to investigate the agent used for tamponade at the end of the surgery. Preoperative hole duration and size as measured using optical coherence tomography as well as successful postoperative hole closure were recorded. Use of gas or air was not randomized and was instilled at surgeon discretion. Results: The final analysis included 211 eyes. Gas was used as the tamponade agent in 171 of the 211 eyes; most of these eyes (144 of 171) received sulfur hexafluoride (SF6) and the remainder received perfluoropropane (C3F8). Forty eyes underwent only a complete fluid-air exchange without any gas placement following vitrectomy. There was no statistically significant difference between the 2 groups in mean preoperative macular hole size (P = .43). Nine of the 171 macular holes receiving gas tamponade failed to close (5.3%). One of the 40 macular holes receiving only air failed to close (2.5%). There was no statistically significant difference in hole closure rates between the 2 groups (P = .45). Conclusions: Air served as an equally efficacious internal tamponade agent in comparison to nonexpansile gas following idiopathic FTMH repair surgery.

External Choroidal Drainage Using Direct Visualization.

Laura L. Snyder Shriji N. Patel A woman in her 60s with a functional glaucoma tube shunt presented after vitrectomy for epiretinal membrane peeling with symptomatic choroidal effusions not responsive to medical therapy. She underwent a minimally invasive, transconjunctival choroidal drainage procedure, which was directly visualized under a widefield viewing system to prevent intraocular hemorrhage or retinal penetration of the needle. This allowed for preservation of her conjunctiva, restoration of normal intraocular pressure by temporary blockage of her tube shunt with a viscoelastic, and resolution of her choroidal effusions.

Three-Year Findings on Intraocular Pressure Changes in The Prospective Retinal and Optic Nerve Vitrectomy Evaluation (PROVE) Study.

BACKGROUND AND OBJECTIVE: This paper reports 3-year intraocular pressure (IOP) outcomes of the Prospective Retinal and Optic Nerve Vitrectomy Evaluation (PROVE) study. PATIENTS AND METHODS: The prospective, controlled, observational study included 80 eyes of 40 participants undergoing routine pars plana vitrectomy. Study patients underwent preoperative evaluation and multimodal testing of the study (surgical) and fellow (control) eye. This testing was repeated at 3 months postoperatively and then annually for 3 years. RESULTS: Thirty-two of 40 patients (80%) completed 3-year follow-up. At 3 years postoperatively, there was no difference in IOP measurements in surgical eyes overall from baseline (P = .36). Subgroup analysis of pseudophakic eyes at baseline showed a significant elevation in IOP from 14.3 mm Hg ± 2.9 mm Hg at baseline to 16.8 mm Hg ± 3.2 mm Hg at 3-year follow-up (P < .029). Fellow eyes did not experience a significant change from baseline. CONCLUSION: The authors' 3-year results show that IOP is consistently and significantly elevated in pseudophakic eyes compared to baseline following routine vitrectomy. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:371-376.].

Computing uveal melanoma basal diameters: a comparative analysis of several novel techniques with improved accuracy.

BACKGROUND: We sought to compare the accuracy of standard and novel echographic methods for computing intraocular tumor largest basal diameter (LBD). DESIGN: Multicenter, retrospective cohort study. SUBJECTS: All patients presenting with new diagnosis of uveal melanoma (UM). METHODS: Ultrasounds were obtained for all patients, and axial length (AL) was measured for a subset of patients. LBD was calculated as: (1) a single chord measured on B scan ultrasound (one-chord method [1CM]), or (2) by subdividing the basal diameter into two chords, which were summated (two-chord method [2CM]), or (3) by a mathematically-derived formula (MF) based on geometric relationships. The accuracy of each method was then compared, and sensitivity of each technique to factors such as tumor size and AL were analyzed. MAIN OUTCOME MEASURES: Accuracy, robustness, correctness of predicted plaque size. RESULTS: 116 UMs were analyzed; 1CM-calculated LBD underestimated 2CM-calculated LBD by 7.5% and underestimated LBD by MF by 7.8%; 2CM and MF were tightly correlated (average LBD difference = 0.038%). At larger LBDs, 1CM underestimated 2CM and MF by a much greater percentage (p < 0.001). By linear regression, 1CM underestimated LBD compared to 2CM by 0.8% and underestimated LBD compared to MF by 1.2% for every 1-mm LBD increase (p < 0.001 for each). Increasing the number of ultrasound chords beyond two did not significantly impact LBD calculations. For eyes with AL within two standard deviations of the mean, AL did not impact plaque selection using MF. 1CM would have led to selection of an undersized plaque in 41% of cases compared to 2CM and would have misclassified half of all eyes that actually required enucleation. For tumors with LBD < 12 mm, 1CM does not significantly underestimate LBD. CONCLUSIONS: Tumor LBD by 1CM is an inaccurate means of determining actual LBD, especially for larger tumors. Using either 2CM or MF is much more accurate, especially for tumors > 12 mm, where a single chord on ultrasound is more likely to lead to incorrect, undersized plaque selection. Our MF can be applied with great accuracy even in cases where the AL of the eye is not measured, using the population average AL (23.7 mm), and the formula LBD = 23.7 sin - 1 ( chord length / 23.7 ) .